Flu Vaccine for Everyone! was developed by the Massachusetts Department of Public Health (MDPH), Office of Health Equity. We wish to acknowledge the many individuals and organizations that generously contributed their time and efforts to make this guide a reality. We would especially like to thank the Immunization Program in the Bureau of Infectious Disease Prevention, Response and Services at MDPH for its contribution.

We also wish to acknowledge other attendees to the 2011 Massachusetts Association of Public Health Nurses conference who took the time to review this guide in its draft format.
This publication was supported in part by the cooperative agreement award number 1H75TP000378-01, Public Health Emergency Response, from the Centers for Disease Control and Prevention and by grant number STTMP101046-01, State Partnership Grant from the U.S. Office of Minority Health. Its content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention or the U.S. Office of Minority Health.

What’s New in Flu Outreach and EducationToday, we face a new challenge: to get flu vaccines to those who have traditionally been hard to reach. Especially at risk are racially, ethnically and linguistically diverse populations that are often isolated and have limited access to health information.

The best way to protect the most vulnerable individuals is to vaccinate everyone. Our challenge today is to get the word out about the importance of flu vaccination.

INote: We understand that many local health departments and community-based organizations have limited resources to apply to a flu outreach campaign. While some strategies discussed in this guide have a moderate cost, others are completely free. Choose those that are feasible in your community, or look to regional resources to amplify your efforts.ntroduction

The Flu Outreach Guide you are holding is designed to help your health department or community-based organization truly reach the communities that need flu vaccine the most. The community health approach to flu vaccination has changed a great deal in the last few years. In the past, public health officials focused most of their efforts on seniors and people with chronic health conditions. Today, vaccination is recommended for almost everyone over the age of six months. We face a new challenge: to get flu vaccines to groups that have traditionally been hard to reach. Racial, ethnic and linguistic (REL) populations are often isolated and have limited access to health information. As we work together to find ways to educate individuals, we can help reduce disparities in flu vaccination, a priority for the Massachusetts Department of Public Health.

Very real barriers stand in the way of our efforts to get the flu vaccine to those who need it most. We must remain responsive to the changing diversity of our communities—understanding where people live and how they receive services. We need to be aware of new arrivals in our neighborhoods, even as continuing shifts in populations keep us on our toes.

Why did flu vaccine recommendations change?

Anyone can get the flu, and most importantly, anyone can give the flu to somebody else. Children can give it to their grandparents; babysitters can give it to newborns; workerscan give it to co-workers who may have unknown health problems; and familymembers can give it to people in their households who may be at risk for seriouscomplications of flu. A mild case of flu for one person may be deadly to another person.

Each year brings new strains of the flu virus, and each of these new viruses may beespecially harmful to particular groups of people. For example, the 2009 H1N1 (swine)flu caused more deaths among pregnant women than had been seen before withinfluenza. Because of this uncertainty as to who will be the hardest hit, the best way to protect the most vulnerable individuals is to vaccinate everyone. Our challenge today isto get the word out and educate everyone about the importance of flu vaccination. Onlyby doing this will we be able to protect those who need it most.

Today, the highest rates of vaccination are among those over 65. Not only have public health departments and providers made great progress in getting the flu vaccine to seniors, but seniors themselves are also seeking out their annual flu shots at flu clinics, in their providers’ offices, and in pharmacies. Still, even among seniors, rates of vaccination for Hispanics and African-Americans are lower than for whites. Public health departments and community agencies now need to focus on community members who may not have had access to vaccination. Often, these community members already face greater health risks because of racial, ethnic and linguistic barriers to care and services, as well as the increased burden of chronic diseases that put them at risk. This guide is designed to help local community agencies and public health departmentsshare innovative strategies to reach these community members.

Underserved communities stand to benefit the most from flu vaccination but also suffer the greatest loss when they are not vaccinated. For example, in Massachusetts, African Americans have the lowest rates of flu vaccination and are more likely than whites to be hospitalized—or even die—from seasonal flu. During the H1N1 (swine) flu outbreaks in 2009, African American children and pregnant women had the highest rates of complications. In addition, higher rates of chronic diseases such as asthma, hypertension and diabetes among REL populations place them at much higher risk of getting seriously ill from the flu. For example, a five-year-old with asthma who gets flu from a healthy schoolmate may miss weeks of school when she gets complications and ends up in the hospital.

Health education messages, often in English, are hard to understand for non-English speakers. New arrivals to the U.S., as well as underinsured, low-income groups or those not connected to services, may not even be aware that they are at risk of getting the flu. Some groups may not trust public health messages due to past histories of discrimination or bad experiences with public agencies. Despite strong evidence for the safety and effectiveness of the flu vaccine, many people still believe it is unsafe or experimental. All these issues are made worse by logistical obstacles such as inconvenient hours and locations of flu clinics and confusing eligibility and insurance requirements.
How should local health departments respond to flu today?

Public health professionals must rethink and revise their flu vaccination and education efforts to fit the needs of new populations that may be hard to reach. We need to creatively tackle system-wide barriers to flu vaccination such as access, eligibility, language, and hours of operation. Location is an important consideration. When appropriate, providers should consider alternative sites to administer vaccine. As we do this, we will lay the groundwork for future public health efforts by getting to know our community, understanding how members receive and incorporate health information, and finding the best ways and locations for them to access public health services.

Our success depends heavily on the partnerships we can build with community members and organizations that share our common mission. As we work together, we can promote flu vaccination in our communities.

AVaccines protect our communities

There are many health behaviors that are hard to change, such as diet, exercise, weight loss, and smoking. Getting vaccinated against flu is one of the easiest, provided the barriers are removed. It is an easy way for community members to protect themselves and their families.nd while you’re at it...Don’t forget pneumonia vaccine!

Flu vaccination is a great opportunity to educate people about the importance of getting vaccinated against pneumonia. Many people don’t know that the recommendation has changed, and that they may need this as well.

Uninsured people in particular have not had access to the pneumonia vaccine.

Pneumonia vaccine should be given to all adults over 65 years of age, and to adults from 18 to 64 who:

• Smoke

• Have asthma

• Have long-term health problems such as:

Heart disease

Lung disease

Sickle cell disease

Diabetes

Alcoholism

Cirrhosis

Leaks of cerebrospinal fluid or cochlear implant

• Have a condition or take medication that lowers the body’s resistance to infection.

For people with these conditions, the pneumonia vaccine only has to be given once before age 65.

Everyone needs a pneumonia shot after age 65.Flu outreach lays a foundationIn 2009, during the H1N1 flu epidemic, the Cambridge Public Health Department developed a database of all the day care centers in their town. It contained the ages of and number of children served, languages spoken, key personnel names and contact information.

A year later, the health department used this list to send critical information and recommendations during an outbreak of whooping cough.

For community-based organizations:

Offering flu outreach education or clinics can be an easy way to provide a concrete service to your clients—an achievable step on the path to better health. These events also provide the opportunity to market all of your agency’s programs, and to bring in a population that might not have otherwise known about other services available to them.

Further, keeping your constituents and your staff healthy is helpful, not only for the health of your community, but also to prevent staffing shortages and expensive overtime costs. Finally, developing the systems necessary to stop the spread of seasonal flu will find your community more prepared for larger flu outbreaks in the future.

Access to flu vaccine: Is it enough? Can we do better?

Now that annual flu vaccination is recommended for everyone aged six months and older, a diverse network of sources has sprung up to provide the vaccine. It is paid for by health insurance, which in Massachusetts covers 98 percent of the population. Currently, the Massachusetts Department of Public Health (MDPH) supplies free flu vaccines to local health departments to vaccinate those who do not have insurance. Primary care providers and pharmacies are making extra efforts to run flu clinics at convenient times. MDPH has also developed systems to help local health departments participate in billing health insurance for vaccination. Step-by-step guidance and resources are found in the Toolbox on page 32. While the tips in this guide have been created to bring the vaccine to everyone, we encourage local health departments to purchase a vaccine that can be provided and billed for.

Effective outreach requires knowledge of your community, reliability, trustworthiness, creativity and determination. Outreach is based on knowing where to go and how best to communicate a message so that it is heard and understood. It also means being a dependable and easily accessible source of information and support.

To begin, identify those in your community who are less likely to be immunized. Are there populations of recent immigrants, ethnic minorities or others who are at high risk? Start conversations with members of your target groups, and those organizations who serve them, to ensure that your flu prevention effort is successful.

Here are some suggestions to help you learn about your target group:

Study the demographics of your community. Are there groups of people at particularly high risk for flu, or who are less likely to receive primary care? Where do they live? Where do they work?

Visit your town’s website.

Look at census data, and MassCHIP (http://www.mass.gov/dph/masschip).

Visit a library. Check in with your local library, or visit the Massachusetts Department of Housing and Community Development website, which has “Community Profiles” of every municipality in the Commonwealth. MDPH and the Regional Centers for Healthy Communities have large libraries with a wealth of information in multiple languages.

Meet with key community residents to understand their attitudes toward flu prevention. Ask what their greatest needs are and how you can help make their community a healthier place. You might talk to:

Local political leaders, especially those already identified as health champions.

Community organization directors or board members.

Community and social service staff, especially those working directly with high-risk populations.

“Informal” community leaders such as seniors, peer leaders, coaches and school-parent liaisons.

Conduct a community insider discussion. A focused discussion can give you clues about where to focus your intervention. It is an opportunity to identify and engage “community insiders”—members of your community who will help spread the message about flu to their friends, families and colleagues. They can also help you assess your health materials for cultural competency and language.

Invite community members who are part of your target population and are formal or informal leaders, including clergy, employers, teachers or youth group leaders, to the key informant discussions. There is a brief guide to conducting a discussion group in the Toolbox.

The help-seeking behaviors of this community. Who do they turn to when they are ill? Will they attend an event in the evening? Do women need permission from their husbands to participate? Will cold weather keep them away?

What are some important businesses patronized by community members (e.g., beauty salons, barber shops, restaurants, ethnic grocery stores)?

What are their favored media outlets (newspapers, TV, radio)?

(YOU DON’T HAVE TO DO IT ALONE!

Partner with people and organizations in your community who already have connections to the group you want to educate or vaccinate. You will be more successful, have more fun and build important relationships for the future.

Photo courtesy of Manet Community Health Center
See the list of ethnic media in Section 11.)

Identify your community partners

Your most important partners are people and organizations that already have trusted relationships with the community you hope to reach. Both formal and informal leadersare invaluable; with their help, you can implement an effective campaign.

While building these relationships can be challenging and time consuming, remember that you are building the foundation for the future success of your health promotion activities. If you have developed a respectful and trusting relationship with key community leaders, your impact will grow over time.

Begin with the people and organizations you identified in the previous section. Choose the one or two that show the greatest promise for reaching and influencing your target community.

Organizations that exist specifically to serve the needs of the population you are trying to reach are often your best choice—for example, mutual aid programs, ethnic community organizations and churches. Also look for partners who are already serving the health needs of the community, such as lay health leaders in church ministries.

The Massachusetts Department of Public Health’s Refugee and Immigrant Health Program (RIHP) has a significant outreach component staffed by trained bilingual, bicultural individuals who provide the primary link between their communities and the health care delivery system.

RIHP also works to increase understanding of and compliance with medical recommendations and provide basic information about local health care. You may be able to work with one of the individuals assigned to your area by contacting one of the three regional coordinators at (617) 983-6590.

Tips from the

Family Van:

How to reach out

Staffing a table or handing out fliers at a store or street corner requires a special set of skills. These suggestions are from the staff of The Family Van, a Boston-based street outreach team:

Be friendly.

Don’t be shy.

Dress casually—no uniforms.

Be yourself.

Make eye contact.

Don’t be pushy.

Photo courtesy of Tapestry Health

For racially and ethnically diverse and immigrant groups, try to utilize “insiders”— people from the identified target group—to do the outreach and education. They are likely to have the language and cultural skills necessary to communicate your message effectively and are usually trusted in their community. Don’t forget to provide vaccines toyour volunteers and address any myths or reservations they might have about getting a flushot. You want them to have excellent “street cred” (street credibility). By providing them withthe right information, you can make them allies who can help overcome the skepticism ofcommunity members.

Other potential partners and outreach venues to consider:

Massachusetts Association of Community Health Workers (MACHW)

Pharmacies

Women, Infants and Children (WIC)

English as a Second Language programs (ESL)

Unemployment office

Food pantries

MBTA stations

International food stores

Community action agencies

Chambers of Commerce

Minority-owned businesses

YMCA, YWCA, Boys and Girls Clubs and other athletic or recreational facilities

Community partners can play a critical role in developing and implementing your flu initiative. While some communities may have many potential partners, you will need at least one partner that can bring resources, knowledge, skills and credibility to the initiative.

Ask yourself:

Does this organization interact regularly with many residents from your target group? Are these the people whom you hope to vaccinate? (For instance, churches may connect with more elders, and YMCAs with more men. Some agencies work with recent immigrants, but not with those who have been here many years.)

Do they employ bilingual and bicultural staff?

Do they already have a health promotion program?

Is there a key employee who has the power to influence the health practices of your community?

How do community insiders feel about this organization?

Does the organization have the capacity to help you with your flu initiative? Can it identify a staff person to work with you, offer space or share their mailing list?

Does the organization have a history of working successfully with government or social service agencies?

Photo courtesy of Cambridge Public Health Department

Vote & Vax

Vote & Vax works with local public health providers to help them launch vaccination clinics at or near polling places across the country. The Robert Wood Johnson Foundation recognized this opportunity to safely and conveniently provide flu vaccinations on Election Day, and provides technical assistance and support to participating communities. Try this strategy in diverse neighborhoods with a high percentage of residents at risk for flu.

For more information on how to participate, visit http://www.voteandvax.org.

Photos courtesy of Manet Community Health Department

Outreach strategies

Outreach is hard work, but it is effective. There is no substitute for being out in the community and meeting people. Possible places to go include supermarkets, bodegas, laundromats, barbershops, beauty salons, libraries, parks, sports and community events. Go to where people live, congregate and shop, and engage them one-on-one.